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In real clinical practice, such methods, and even in combination, are not performed in patients with GERD, therefore, almost all patients with functional heartburn are diagnosed with a non-erosive form of GERD. Data on the prevalence of patients with functional heartburn is clearly overestimated. 10% of all patients visiting a gastroenterologist were obtained only on the basis of the results of daily pH monitoring. Impedancemetry was not carried out by them. We do not know how many of these 10% of patients with heartburn were non-acid reflux patients.

Another interesting possible reason, which was announced only in the last week of American gastroenterology. The Belgian group of Jan Pak, a very well-known specialist in gastroesophageal reflux disease, showed that the clinical symptoms of GERD do not correlate with the parameters of gastroesophageal reflux, but with the presence of anxiety disorders and the degree of somatization. Sometimes it is advisable for patients with persistent heartburn to consult with a psychotherapist.

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Another reason for the ineffectiveness of acid-suppressive therapy is the misinterpretation of other forms of esophagitis as a manifestation of gastroesophageal reflux disease. Other forms of esophagitis can also occur with heartburn as the leading clinical syndrome. What applies to other forms of esophagitis? This is, first of all, fungal (candidiasis) esophagitis.

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It is viral (cytomegalovirus). These forms of esophagitis usually occur in immunocompromised patients.

These are elderly patients. Patients who received courses of chemotherapy for cancer or received long-term courses of antibiotics. It is clear that they are resistant to the use of proton pump inhibitors. They should be treated with appropriate antifungal or antiviral drugs. Drug-induced esophagitis can most often occur after the appointment of non-steroidal anti-inflammatory drugs. Radiation esophagitis - in patients who have undergone radiation therapy for either breast or lung cancer. This is an example of candidal esophagitis. Cream-colored plaques, after the removal of which rather deep flushing erosions remain.

Cytomegalovirus esophagitis also with characteristic raids. The danger of radiation esophagitis lies in the fact that in the late period, many years after the irradiation, the connective tissue grows. Radiation esophagitis is complicated by the formation of cicatricial stricture of the esophagus. One form of esophagitis that can be mixed with the resistant form is eosinophilic esophagitis. Much has been written about him in the past few years. This form of esophagitis is characterized by an increase in the content of eosinophils in biopsy specimens of the esophageal mucosa up to 15 per field of view.

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What is the modern therapeutic tactics for resistant forms of GERD? What we can do? First of all, increase the daily dose of protease inhibitorsonnoy pump. Switch the patient from a single dose of proton pump inhibitors in the morning to two doses in the morning and evening. Even this measure can reduce the frequency of resistant forms of GERD by about half. Although it must be remembered that increasing the dose may be accompanied by an increase in the frequency of side effects of proton pump inhibitors.

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This is an allergic disease. Very often it is combined with such nosological forms as bronchial asthma, allergic rhinitis, eczema, food allergies. What is the question here? Is the choice of proton pump inhibitors correct? Are all proton pump inhibitors the same? To some extent, yes, they are the same in terms of mechanisms of action. But they are not the same in the beginning of the action, in the duration of the antisecretory effect.

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Another possibility is a combination of proton pump inhibitors with an H2 blocker. In the 1990s, when proton pump inhibitors appeared, they were shown to have greater antisecretory activity than H2 blockers.
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